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October 2002
Outpatient Surgery
Letters & Emails
Views on Containing Post-op Pain
Pre-emptive analgesia starts before the surgical incision and before the injection of the local analgesia (“New Ways to Contain Post-op Pain,” August, p. 24). Titrating a BIS-monitored propofol infusion to 70-75 before administering a 50-mg dissociative dose of ketamine is the critical component missing in all previous Level I studies of preemptive analgesia. Blocking the NMDA receptors with a dissociative dose of ketamine not only produces an immobile patient for the local analgesia injection but also sets the stage for genuine pre-emptive analgesia. My patients are routinely pre-oped with oral clonidine 0.2 mg and rofecoxib 50 mg 30-60 mg before induction. I have not used any opioids in my practice since December 1997 (without inflicting suffering in my patients).
The key to managing post-op pain is similar to managing post-op PONV — don’t cause it in the first place! Avoid emetogenic opioids for analgesia and precede the local anesthetic injection with a 50 mg dissociative dose of ketamine under adequate propofol hypnosis.
Barry L. Friedberg, MD
Cosmetic Surgery Anesthesia
Corona del Mar, Calif.
drfriedberg@doctorfriedberg.com